Treatment of Inflammatory Cytologic Abnormalities Detected By Pap Smears

Abstract & Commentary

Synopsis: There appears to be no clinical benefit to treatment of inflammatory cytologic abnormalities.

Source: Webb J, et al. Journal of Lower Genital Tract Disease. 2001;5(2):82-84.

For many years, it has been the practice of
many clinicians to prescribe intervaginal or oral antibiotic therapy to patients who have a Pap smear showing inflammatory cytologic abnormalities. The rationale for such therapy has been repeatedly questioned yet the practice persists.

Webb and associates in this pilot study asked all women who had a Pap smear report which showed inflammatory cytologic abnormalities at their institution to participate in this study. Patients who agreed were assigned to 1 of 2 oral metronidazole regimens, vaginal metronidazole, or no therapy.

This study included 159 women. The method of patient assignment did not result in equal sized treatment groups. However, when the data from the 4 groups were compared, Webb et al could not demonstrate a statistically significant difference among the groups. Webb et al conclude that empiric antibiotic treatment of women with inflammatory changes on Pap smears is not clinically indicated.

Comment by Kenneth L. Noller, MD

I have always wondered where the practice of treating inflammatory cells on Pap smears with antibiotics came from. The test was not designed to detect infection, and the presence of such cells does not mean an infection is present. The fact that there are some white cells present on the slide does not mean that anything needs to be, or should be treated. Even though cervical cytology can detect the presence of fungal organisms, changes consistent with BV, and trichomonads it is not clear that any of these should be treated unless the patient has symptoms. Indeed, in the revision of the Bethesda terminology that is currently being considered the whole category of "benign cellular changes" is probably going to be eliminated.

While this was not a great study (lack of randomization of treatment arms, nonblinding, inadequate sample size, etc) it did fail to detect any significant difference in Pap smear reports subsequent to antibiotic therapy vs. placebo. There have been prospective, randomized, clinical trials performed and they also have failed to detect any basis for treatment of inflammatory smears with antibiotics. Unfortunately, the practice persists.